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Post-Test - Found in Translation: Insulin Therapy and Glycemic Pattern Recognition in Clinical Practice


INSTRUCTIONS: Select the most appropriate response. To receive credit, participants must earn a score of 70% or higher.

1. Julia is 58 years old and has had T2DM for 6 years. Her A1C and BMI at diagnosis were 8.1% and 31 kg/m2, respectively. She was on metformin monotherapy for the first 3 years after her diagnosis, followed by the addition of a DPP-4 inhibitor for the next 2 years. Twelve months ago, she added basal insulin therapy at bedtime and started walking for 30 minutes each afternoon after work. At her last visit, which was 3 months ago, she had successfully titrated her basal insulin to 42 U/d and had lost 2 kg. At her current visit, she is still taking 42 U/d of basal insulin, but motivated by her weight loss success, she has intensified her afternoon workout to include 45 minutes of aerobic activity and 20 minutes of strength training. She’s lost an additional 4 kg, but she reports that lately she’s felt a little shaky in the morning. She presents the following report of average glucose readings for the past week.

Before breakfast

58 mg/dL

2 h after breakfast

212 mg/dL

Before lunch

152 mg/dL

2 h after lunch

179 mg/dL

Before dinner

115 mg/dL

2 h after dinner

 170 mg/dL

Before bed

111 mg/dL

What should be addressed first in adjusting Julia’s glycemic control regimen?

A: Hypoglycemia before breakfast
B: Hyperglycemia 2 h after breakfast
C: Hypoglycemia before lunch
D: Hypoglycemia before dinner

2. After commending Julia on her recent weight loss efforts, what regimen adjustment should you recommend?
A: Discontinue the oral antihyperglycemic agents
B: Switch to a premixed insulin
C: Counsel her to eat a larger bedtime snack
D: Decrease her basal insulin dose by 4 U/day

3. Which of the following SMBG patterns would prompt you to increase a patient’s evening basal insulin dose?
A: All premeal levels > 130 mg/dL and all postprandial levels > 180 mg/dL
B: All premeal levels < 130 mg/dL and all postprandial levels > 180 mg/dL
C: Postbreakfast > 180 mg/dL and prelunch level > 130 mg/dL
D: Postlunch level > 180 mg/dL and predinner level > 130 mg/dL

4. In the AT.LANTUS and PREDICTIVE 303 trials of patient-titrated basal insulin dosing algorithms, increments for patient dose adjustments of basal insulin were
A: 0-3 U/day
B: 6-8 U/day
C: ± 10% of the previous dose
D: ± 25% of the previous dose

5. In the AT.LANTUS and PREDICTIVE 303 trials of patient-titrated basal insulin dosing algorithms, patient-adjusted dosing resulted in
A: A1C levels significantly higher than those achieved with physician-adjusted dosing
B: A1C levels similar to those achieved with physician-adjusted dosing
C: Significantly increased rates of hypoglycemia compared with physician-adjusted dosing
D: Significantly decreased rates of hypoglycemia compared with physician-adjusted dosing

6. A trial comparing algorithms for patient-titrated prandial insulin using 4-point SMBG measurements (Simple STEP method) or 6-point SMBG measurements (Extra STEP method) demonstrated that
A: 4-point SMBG measurements were inferior to 6-point SMBG measurements for successful patient titration of prandial insulin
B: The risk of hypoglycemia was significantly increased when patients utilized the algorithm based on 6-point SMBG measurements
C: Patients preferred the algorithm using 6-point SMBG measurements over the one using 4-point SMBG measurements
D: Patients could effectively and safely titrate prandial insulin doses using either algorithm

7. Based on data from patients with T1DM, which of the following statements is true regarding the timing of prandial insulin analogue administration?
A: Each of the prandial insulin analogues (lispro glulisine aspart) provide the best postprandial glycemic control when injected at the start of the meal
B: In general the prandial insulin analogues are likely to provide better postprandial glycemic control when injected 15-20 minutes before the start of a meal
C: Insulins glulisine and aspart provide better postprandial glycemic control when administered 30 minutes before the start of a meal
D: The prandial insulin analogues provide the same level of postprandial glycemic control whether they are administered 20 minutes before or 20 minutes after the start of the meal

8. Jonathan is 67 years old and has had T2DM for 12 years. He has been on metformin with basal insulin for the last 3 years. His current A1C is 8.7%, his weight is 91 kg (201 lb), and his BMI is 28 kg/m2. He was hospitalized for a myocardial infarction 3 years ago, has moderate renal insufficiency (eGFR 35 mL/min/1.73 m2), and mentions that he’s had some problems with heartburn and upset stomach. His current basal insulin dose is 48 U/d. Jonathan is surprised to hear that his A1C level is too high because he has been self-titrating his basal insulin to his daily fasting SMBG level. He presents his log, which reveals steady prebreakfast glucose levels of 105-110 mg/dL but no other values. He thinks the A1C level must be wrong and does not want to accept your recommendation to add prandial insulin, but he agrees to get 3 SMBG readings at each of 6-7 time points (before breakfast, after breakfast, before lunch, after lunch, before dinner, after dinner, and before bed) over the next week. When he returns with his SMBG results 1 week later, you thank him for being so thorough, and review his results (table).

 

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

Sun.

Mean

Before breakfast

105

99

103

105

102

107

100

103

2 h after breakfast

 

 

 

182

236

212

 

210

Before lunch

167

142

171

 

 

 

 

160

2 h after lunch

 

 

 

297

392

358

 

349

Before dinner

181

194

201

 

 

 

 

192

2 h after dinner

 

 

 

243

183

240

 

222

Before bed

182

154

174

 

 

 

 

170

He acknowledges that his blood sugars are high and that he knows he needs to do something. In discussing the possibility of adding 1, 2, or 3 prandial insulin doses, he says, “Whoa! Whoa, doc! Let’s just start with 1 and see how I do.” What is the best way to proceed?

A: Add 4 U prandial insulin before breakfast
B: Add 4 U prandial insulin before lunch
C: Add 4 U prandial insulin before dinner
D: Add a DPP-4 inhibitor until he’s ready to move to 3 prandial insulin doses per day
E: Add 4 U prandial insulin before each meal despite Jonathan’s hesitation

9. Which of the following is true with regard to the use of incretin-based therapies in combination with insulin?
A: No significant A1C improvement was observed when DPP-4 inhibitors were added to regimens including insulin
B: Decreased weight, but no significant A1C improvement was observed when GLP-1 RAs were added to basal insulin
C: Both a and b
D: Neither a nor b

10. Pharmacodynamic profiles of insulin degludec and pegylated insulin lispro demonstrated sustained activity over 24 hours in patients with T2DM.
A: True
B: False